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Storm Help Command

Welfare and Community Relief Request Form

This form is for the request for service or relief for church members or individuals in present need within the
Please fill out this entire form.
Associated Event   
* Work Order Prepared By
* Home Owners Name:
* Quadrant Form
Verify quadrant this home is located within (Quadrant Map)
Moore Quadrant A    
Moore Quadrant B    
Moore Quadrant C    
Moore Quadrant D    
Moore Quadrant E    
Moore Quadrant F    
Carney/Agra    
Shawnee    
El Reno    
* Street Address
* City and ZipCode
  County Cleveland    
Oklahoma    
Canadian    
Lincoln    
Pottawatomie    
McClain    
Other    
  Additional Directions To Home
  Home Phone
Area Code and Number
  Cell or Alternate Phone
area code and cell number
  Person Status First Responder     Community Member     Ward Member     Disabled Person    
  What Ward is This Homeowner Associated With?
  Is Occupant Planning To Continue Living In Home? yes     no    
  Is This Home or Structure Habitable? yes     no    
* Home Owner Authorization
Has The Home Owner or Home Owner Representative Authorized The Following Release: RELEASE: I hold the volunteers, including their representatives and agents, harmless from any damage or injury that may occur on my property, including personal property. Further, I understand that no warranty or guarantee, express or implied, is provided for work performed on or for my property.
yes     no    
  What is the name of the person giving authorization for work?
* Work Crews Please phone me to arrange a time for crews to work on the home. I want to be there when they arrive.
I don't need to be there when the crews arrive. I have taken any photos needed for insurance purposes and give permission for repairs and debris removal.
Assessment
  Name Of Person Making Assessment
  Rain and Water Damage
Check Boxes Needed
Furniture Removal
Appliance Removal
Doors to be Removed
Sheet Rock and Insulation Removal
Carpet and Floor Covering Removal
  Water Removal
Check Boxes Needed
Pump Needed
Generator Needed
Basement Flooded
Water on Main Floor
  Roof Damage
Number of 20' x 30' Tarp(s) Needed
  Tree Removal
Total Number of Trees Down
  Small Trees
Number of Trees < 18" Diameter
  Large Trees
Number of Trees > 18" Diameter
  Is Heavy Equipment like Bobcats, Cranes, or Bulldozers Needed To Complete The Job? yes     no    
* Priority of Request Urgent     Intermediate     Minor    
Return and Report
Please write the a description and notes of work that was done in the comments section. Please place your name, ward/stake and notes below. Also state if the task was done, partially complete, or nothing was needed. The number of others helped and neighbors you participated with. To see submitted work orders or status of them go to http://clients.fastcommand.com